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LETTER TO EDITOR  
Year : 2017  |  Volume : 59  |  Issue : 3  |  Page : 389-390
Significant improvement of posttraumatic stress disorder and psychotic symptoms after inpatient Eye Movement Desensitization and Reprocessing treatment: A case report with 6-month follow-up


1 Department of Psychotraumatology, Clinic St. Irmingard, Osternacher Strasse 103, 83209 Prien am Chiemsee, Germany
2 Schoen Clinic Roseneck, Am Roseneck 6, 83209 Prien am Chiemsee; Department of Psychiatry, Ludwig-Maximilians.-University, Nussbaumstrasse 7, 80336 Munich, Germany

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Date of Web Publication6-Oct-2017
 

How to cite this article:
Kratzer L, Heinz P, Schennach R. Significant improvement of posttraumatic stress disorder and psychotic symptoms after inpatient Eye Movement Desensitization and Reprocessing treatment: A case report with 6-month follow-up. Indian J Psychiatry 2017;59:389-90

How to cite this URL:
Kratzer L, Heinz P, Schennach R. Significant improvement of posttraumatic stress disorder and psychotic symptoms after inpatient Eye Movement Desensitization and Reprocessing treatment: A case report with 6-month follow-up. Indian J Psychiatry [serial online] 2017 [cited 2019 Nov 17];59:389-90. Available from: http://www.indianjpsychiatry.org/text.asp?2017/59/3/389/216185




Sir,

Recent findings suggest a relationship between psychological trauma and schizophrenia spectrum disorders [1] that is partially mediated by posttraumatic stress symptoms.[2] Even though there is evidence that trauma-focused treatments are beneficial for patients with psychotic symptoms,[3] patients with psychosis are still often excluded from first-line treatments of posttraumatic stress disorder (PTSD) due to fears that psychotic symptoms might exacerbate during trauma reprocessing. We want to encourage clinicians to apply trauma-focused therapy to patients with PTSD and psychotic symptoms.

Our patient was a 53-year-old woman diagnosed with PTSD and schizotypal personality disorder according to Diagnostic and Statistical Manual of Mental Disorders, 4th Edition criteria. She reported flashbacks, insomnia, nightmares, avoidance, hyperarousal, severe derealization and depersonalization, feelings of guilt, constricted affect, obsessive ruminations with aggressive and sexual content, magical thinking, paranoid ideas, social phobia, and visual, body, and acoustic hallucinations. Her trauma history was assessed using the Childhood Trauma Questionnaire and consisted of childhood sexual abuse, emotional abuse and neglect. For more than 20 years, she had had several suicidal crises, inpatient, and outpatient treatments. At the time of admission, her stable medication consisted of 15 mg aripiprazole, 350 mg quetiapine, and 375 mg venlafaxine. She was in early pension and described to profit from outpatient cognitive behavioral therapy (CBT) and medication. Yet, so far nothing had helped to significantly reduce intrusions, nightmares, and hallucinations.

The patient received a multimodal, integrative, and disorder-specific inpatient treatment with various group therapies, for example, psychoeducation, mindfulness training, art therapy, exercise therapy, emotion regulation, and social skills trainings.[4] Case conceptualization followed the Eye Movement Desensitization and Reprocessing (EMDR) guidelines for psychosis [5] and the cognitive model of psychosis.[6] Treatment lasted 12 weeks and consisted of 16 individual 50-min treatment sessions of CBT and ten additional 100-min sessions of EMDR. Symptom levels were assessed daily using an individualized diary card. We used standard EMDR to process traumatic memories of childhood sexual abuse, whereas the goal of reducing psychotic symptoms was targeted by processing hallucinations associated to the patient's dysfunctional beliefs about the world and herself (”The world is dangerous,” “I cannot protect myself”). For example, we targeted a recurring hallucination of body disintegration and penetration of body boundaries related to the cognition “I am lost,” tonic immobility, disgust and panic. EMDR helped the patient to form alternative cognitions like “I can help myself” and significantly reduced aversive emotions.

Even though the patient described EMDR sessions as demanding and frightening, she considered them helpful for “finally learning to express in words what happened.” After an initial increase of anxiety, hallucinations and dissociative experiences, symptoms decreased. The score for intrusions in the Impact-of-Event Scale–Revised remained stable from first assessment to dismissal (from 31/35 to 29/35) but had decreased significantly 6 months after dismissal (4/35; improvement of 2.6 standard deviation [SD]). The reduction of avoidance symptoms (22/40-15/40) was maintained at follow-up (12/40; improvement of 1.1 SD). Hyperarousal decreased significantly, too (from 26/35 to 19/35 to 5/35; improvement of 1.9 SD). These improvements reflect both reliable and clinically significant changes. In the HEALTH-49, the patient described significant reductions of depressive symptoms (from 3/4 to 0.7/4 to 0.2/4; improvement of 2.8 SD), anxious symptoms (from 3/4 to 1.8/4 to 0.2/4; improvement of 3.0 SD), and interpersonal difficulties (from 3.1/4 to 2.6/4 to 2.1/4; improvement of 0.9 SD). We also observed significant changes in self-efficacy (from 2.2/4 to 3/4 to 3.8/4; improvement of 1.7 SD) and mindfulness (from 61/120 to 83/120 to 99/120; 3.3 SD) which was assessed using the Freiburg Mindfulness Inventory. The Dissociative Experiences Scale–Taxon score decreased from 18% to 1% and remained stable at follow-up (1%). The PANSS score decreased from 64 to 46 which reflects a clinically important difference.

In sum, reprocessing of traumatic memories effectively helped the patient to remit from PTSD and positive psychotic symptoms. Symptom levels had decreased even further at 6-month follow-up. The patient reported that her disturbing “images” had vanished, that she felt well, that she could now “handle everyday life” and that she was doing voluntary work. She decided to end her outpatient CBT treatment but still consults her psychiatrist regularly. As we observed initial increases of psychotic symptoms, inpatient treatment might be a useful option in the treatment of PTSD and psychotic symptoms.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Berenbaum H, Valera EM, Kerns JG. Psychological trauma and schizotypal symptoms. Schizophr Bull 2003;29:143-52.  Back to cited text no. 1
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2.
Choi JY, Choi YM, Kim B, Lee DW, Gim MS, Park SH, et al. The effects of childhood abuse on self-reported psychotic symptoms in severe mental illness: Mediating effects of posttraumatic stress symptoms. Psychiatry Res 2015;229:389-93.  Back to cited text no. 2
    
3.
van den Berg DP, de Bont PA, van der Vleugel BM, de Roos C, de Jongh A, van Minnen A, et al. Trauma-focused treatment in PTSD patients with psychosis: Symptom exacerbation, adverse events, and revictimization. Schizophr Bull 2016;42:693-702.  Back to cited text no. 3
[PUBMED]    
4.
Heinz P, Pfitzer F. Disorder-specific inpatient treatment of adults with complex trauma histories: The treatment programme of the psychotraumatology ward of Clinic St. Irmingard, Prien am Chiemsee. Trauma Z Psychotraumatol Anwendungen 2014;12:26-37.  Back to cited text no. 4
    
5.
van den Berg DP, van der Vleugel BM, Staring AB, de Bont PA, de Jongh A. EMDR in psychosis: Guidelines for conceptualization and treatment. J EMDR Pract Res 2013;7:208-24.  Back to cited text no. 5
    
6.
Garety PA, Kuipers E, Fowler D, Freeman D, Bebbington PE. A cognitive model of the positive symptoms of psychosis. Psychol Med 2001;31:189-95.  Back to cited text no. 6
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Correspondence Address:
Leonhard Kratzer
Department of Psychotraumatology, Clinic St. Irmingard, Osternacher Strasse 103, 83209 Prien am Chiemsee
Germany
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_318_16

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